How Should Doctors Break Bad News?

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Deborah Lewis, a former lawyer living in Washington, D.C., found out she had breast cancer over the phone. She remembers the day clearly. She was in her car on a “stunningly beautiful September morning” when her cellphone rang. “ ‘We have an unpleasant surprise,’ ” she recalls her surgeon saying. “It was there in my car, on the side of the road, that I became a cancer patient.”

When Lewis tells the story, people often react with horror: “The phone? You found out you had cancer in a phone call?”

As doctors, we frequently have to break bad news. It’s one of the toughest things we do: “ Yes, the test showed you are HIV positive”; “I am sorry, but your cancer has returned”; or “The ultrasound indicates the baby is dead.” Some medical schools and residency programs are now teaching young doctors how to break bad news.

The general guidelines are straightforward: Take the patient or family to a private area, close the door, sit down together, make eye contact, say it with empathy, listen, touch, and be open to questions. The message is clear: Do it in person. “I try to avoid giving bad news over the phone,” says Rhonda Fishel, associate professor of surgery at the Johns Hopkins University School of Medicine in Baltimore. Dr. Fishel wants to see the patients’ reactions: “I pace myself according to their physical cues.”

If you are having a diagnostic test, a biopsy, or an important blood test, you’re usually told to schedule an appointment to discuss the findings. That’s because many doctors’ offices across the country mandate that results be delivered in person.

And then the wait begins. It can be a couple of days, but sometimes it takes more than a week. A recent study in the journal Radiology suggests that the waiting period itself can be bad for your health. Researchers measured the level of the stress hormone cortisol in 130 women who were awaiting their breast biopsy results. They found that the levels of cortisol in patients who had not yet received their results after five days were “essentially indistinguishable” from those found in women with an actual diagnosis of breast cancer. High cortisol levels—aside from suggesting high stress levels—c an affect various body functions, from immune-system responses to the regulation of blood sugar, blood pressure, and even the healing of wounds (important if you’ve just had an invasive procedure, such as a biopsy).

Waiting for biopsy results, Deborah Lewis says, is “a slow form of torture.” So scheduling an appointment makes no sense to her. “I want to know the results as soon as the doctor does. If he requires me to come in for an office visit to get the results, that means he’s had them for at least a number of hours, probably days, before I get the news. Those are hours or days of suffering.” She thinks the phone is the way to go.

In fact, a study in the American Journal of Surgery showed that about 40% of patients received a cancer diagnosis over the phone while 2% were given their diagnosis by mail. The majority of women surveyed for that study indicated that they preferred to get the news in person, and 73% believed it was important to have the doctor’s “full attention” and that eye contact was important.

There was no eye contact or touch for Lewis, but she thinks that hearing the news over the phone was a compassionate thing. “It allows the patient to react fully in private. The patient can yell, cry, scream, and not have to be mindful of the doctor’s presence. Then, when the patient does go in to see the doctor, he or she can listen to the information, process it, and ask questions.”

However the news is delivered, Dr. Fishel notes, empathy is important. “It’s possible to be impersonal in a face-to-face meeting and warm and compassionate over the phone,” she acknowledges. Discuss with your doctor ahead of time how you’ll be getting your news—good or bad—and make your wishes clear.